Skip to main content

MACs, RACs, OIG, ZPICs, CERTs and the HEAT….Who’s watching you?

October 21, 2013

When we think of Fraud and Abuse auditing most of us think of the OIG or Office of Inspector General but they have company now. The recoupment record for this enforcement organization was such a resounding success that now, not only the feds but the states and contractors have jumped on the auditing bandwagon to reduce waste and combat fraud. Who is out there watching? Where are they getting the data? What is their motivation?

There are many groups but let me define the top six.

MAC – Medicare Administrative Contractor – These are the companies that process and pay Medicare claims for both Part A and Part B. Now that one organization is processing both parts, MACs can compare Part A and Part B services for discrepancies. These audits and edits are placed in the prepayment state of a claim. This prepayment review can affect your cash flow dramatically.

RAC – Recovery Audit Contractors – RACs are the private bounty hunters of health care fraud. RACs are paid on a contingency basis. They are private “for-profit” organizations. The more they recoup, the more they make.  RACs are going after the high error rate high dollar areas. RACs publish exactly what they will be investigating….there is no excuse for being surprised.

OIG – Office of Inspector General – Every federal agency has an Inspector general. The HHS OIG is one of the largest. This is a legal auditing federal entity responsible for reporting to the Executive branch and the Congress. The OIG published a Work Plan every year….find it, read it, prepare for it.

ZPIC – Zone Program Integrity Contractors – Once a fraud or abuse issue is identified within a MAC jurisdiction it is escalated to a ZPIC. ZPICs work with the DOJ and the FBI when the likelihood of fraud is high. ZPICs have the power to suspend claims for up to a year without any appeal rights.

CERT – Comprehensive Error Rate Testing – The intent of these testing agencies was to monitor the quality of the work of the contractors and FIs. Identifying the errors on contractor had a great side affect. Once the errors were corrected….money was recouped. The program began to fund itself….it is not going anywhere!

HEAT – Health Care Fraud Prevention and Enforcement Action Team – Around since 2009, this more aggressive investigator uses data mining and analytics in partnership with federal, state, local and private sector groups to combat fraud.

Everyone in a healthcare office, clinical or administrative, should know the names of these groups. Everyone should all know how to react appropriately to either a personal visit or a written request for information. Raise the bar of compliance in you clinic! Eventually one of these groups will get around to you….are you ready?

Get the Latest RCM News Delivered

Receive practical tips on medical billing and breaking news on RCM in your inbox.

Get in Touch